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increasing the pain associated with future procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Until recent years&#44; the management of pain and anxiety in children was one of the most neglected aspects of care in paediatric emergency departments &#40;PEDs&#41; due to the very nature of emergency care&#44; in which time is a critical factor&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> However&#44; in the past few years there has been a growing interest among paediatric emergency physicians in providing adequate sedation and analgesia &#40;SA&#41; to their patients&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Today&#44; the need for sedation and analgesia is considered indisputable&#46; It is also understood that the correct management of SA and patient safety during its administration require not only the identification of the need for SA&#44; but also adequate training of the staff that delivers SA to minimise and correctly address its risks&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;4</span></a> Thus&#44; adequate staff training and protocol development are crucial to the safety of paediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2009&#44; the Working Group on Analgesia and Sedation of the Sociedad Espa&#241;ola de Urgencias de Pediatr&#237;a &#40;Spanish Society of Paediatric Emergency Medicine &#91;SEUP&#93;&#41; developed the first manual on analgesia and sedation in the paediatric emergency setting&#44; followed by the introduction in 2015 of a nationwide register of SA procedures performed in Spanish PEDs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of our study was to analyse the preparation of SA procedures in 18 PEDs in Spain&#44; and to find out the characteristics of the patients that underwent these procedures&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a multicentre&#44; prospective&#44; observational and analytical study of the SA procedures performed in a 1-year period in participating PEDs&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study was approved by the institutional research ethics committees of each participating centre and adhered to the principles of the Declaration of Helsinki&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We obtained the informed consent of the parents or legal guardians of each of the patients included in the study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study universe and setting</span><p id="par0050" class="elsevierStylePara elsevierViewall">We conducted the study in 18 PEDs associated with the Working Group on Sedation and Analgesia of the SEUP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; between February 1&#44; 2015 and January 31&#44; 2016&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We selected children that visited any of the participating PEDs and underwent some type of SA procedure with a dissociative drug&#44; opioid analgesic and&#47;or sedative&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The inclusion criteria were age 0&#8211;18 years and signing of informed consent form by the parents or legal guardians and&#44; in patients aged more than 12 years&#44; the patient as well&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We excluded children that did not meet the inclusion criteria or for whom we were unable to obtain signed informed consent&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data collection</span><p id="par0070" class="elsevierStylePara elsevierViewall">A data collection notebook was filled out for each study participant&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Each facility encoded the notebooks with an alphanumeric code to safeguard the confidentiality of patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Every month&#44; the researchers in each centre submitted the data on the procedures performed in their facilities electronically to the principal investigator&#44; who was responsible for the study database&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We collected <span class="elsevierStyleItalic">epidemiological variables</span>&#44; <span class="elsevierStyleItalic">patient-related variables</span> &#40;physical status classification of the American Society of Anesthesiologists &#91;ASA&#93;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> ongoing pharmacological treatment&#44; fasting&#44; anticipatory anxiety&#44; level of pain before treatment&#44; physical examination&#41;&#44; <span class="elsevierStyleItalic">variables related to the preparation of the SA procedure</span> &#40;reason for SA&#44; type of procedure&#44; monitoring&#44; pharmacological approach used&#44; professional in charge of providing SA&#44; request for informed consent&#44; and presence of parents during the procedure&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Outcome measurement</span><p id="par0090" class="elsevierStylePara elsevierViewall">We classified the type of SA procedure based on the clinical situation into <span class="elsevierStyleItalic">simple analgesia</span> &#40;isolated administration of an opioid drug for the prevention of procedural pain without the intent of producing a state of sedation&#41;&#44; <span class="elsevierStyleItalic">sedation</span> &#40;administration of sedative or antianxiety agents to achieve a depressed level of consciousness of varying degree with the purpose of facilitating patient cooperation in a painless procedure&#44; such as an imaging test&#41; or <span class="elsevierStyleItalic">SA</span> &#40;administration of opioid analgesic and&#47;or topical&#47;local anaesthesia combined with a sedative or administration of dissociative anaesthesia to allow the patient tolerate an unpleasant and painful procedure&#41;&#46; The latter included SA for a mildly painful procedure &#40;such as venepuncture&#44; lumbar puncture or simple wound repair&#41; and SA for very painful procedures &#40;such as closed reduction of fractures or electrical cardioversion&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Pain was measured by means of age-appropriate validated scales &#40;the FLACC observational pain assessment scale&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a> the Wong-Baker FACES rating scale<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> and a numerical scale&#41;&#46; Anticipatory anxiety was measured by means of a scale designed to assess anxiety related to short procedures comprising 2 items&#58; crying and muscle tension &#40;Groningen distress scale&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">We analysed the collected data using the software SPSS version 21&#46;0&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We have expressed categorical variables as absolute frequencies and percentages&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We summarised normally distributed variables as mean and standard deviation&#46; Normality was assessed by means of the Shapiro&#8211;Wilk test&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">We compared means using parametric tests &#40;Student <span class="elsevierStyleItalic">t</span> and ANOVA&#41; or nonparametric tests &#40;Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> and Kruskal&#8211;Wallis tests&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We analysed the association between qualitative variables with the chi square test or the Fisher exact test&#46; We calculated odds ratios with their corresponding confidence intervals to measure the strength of association&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Results with <span class="elsevierStyleItalic">p</span>-values of less than 0&#46;05 were considered statistically significant&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0135" class="elsevierStylePara elsevierViewall">A total of 658 SA procedures were registered between February 1&#44; 2015 and January 31&#44; 2016&#44; of which 404 &#40;61&#37;&#41; were performed in male patients&#46; The mean patient age was 6&#46;6 years &#40;SD&#44; 4 years&#41;&#44; and 592 children &#40;90&#46;7&#37;&#41; were aged more than 2 years&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Out of all SA procedures&#44; 69&#37; were performed on weekdays&#46; Also&#44; 311 &#40;47&#46;9&#37;&#41; were performed in the afternoon&#44; 254 &#40;38&#46;6&#37;&#41; in the morning and 89 &#40;13&#46;5&#37;&#41; at night&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarises the characteristics of the evaluation prior to SA performed in the children included in the study&#46; We ought to note that 6 of the included patients were classified as ASA III&#44; and that 4 of them were managed by paediatric emergency physicians with appropriate training for performing SA procedures in this type of patient&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The duration of fasting was assessed in 538 children &#40;81&#37;&#41;&#46; Fasting time was less than 2<span class="elsevierStyleHsp" style=""></span>h in 50&#46;9&#37; of children that underwent simple analgesia&#44; 46&#46;2&#37; of children that underwent sedation&#44; 31&#46;6&#37; of children that received SA for a very painful procedure and 25&#46;5&#37; of children that received SA for mildly painful procedures&#44; and the difference was only statistically significant between the simple analgesia group and the SA for mildly painful procedures group &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Anticipatory anxiety was assessed in 608 children &#40;92&#37;&#41;&#46; When it came to patient age&#44; and excluding the subset of patients that experienced panic&#44; we observed that anticipatory anxiety increased with decreasing age&#44; although the correlation was weak &#40;rho&#44; 0&#46;18&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> summarises the reasons for use of SA&#44; the type of SA procedures performed&#44; and the type of professional that carried out the procedures&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarises the most frequent reasons that led to the use of SA in our study&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">We analysed the type of SA used based on the type of professional that delivered it and found that paediatric emergency physicians and third- and fourth-year paediatrics residents used SA for mildly or very painful procedures more frequently than nurses or first-year paediatrics residents&#44; who were more likely to use simple analgesia and sedation &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Informed consent for performance of SA was requested in 649 &#40;98&#46;6&#37;&#41; procedures&#59; it was obtained in writing in 444 cases &#40;67&#46;5&#37;&#41; and verbally in the remaining 205 &#40;31&#46;2&#37;&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">We analysed whether consent was obtained in writing or verbally based on the type of SA procedure to be performed&#44; and found that consent was obtained in writing more frequently for SA for very painful procedures &#40;76&#46;6&#37;&#41; compared to SA for mildly painful procedures or simple analgesia &#40;62&#46;9&#37; and 54&#46;4&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>001&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The pharmacological strategy consisted in the administration of a single drug in 443 of cases &#40;67&#46;3&#37;&#41; and of a combination of drugs in 215 &#40;32&#46;7&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the mean age of the patients for each pharmacological strategy&#46; We found that the combination of nitrous oxide and fentanyl was used more frequently in older children &#40;9&#46;34 years&#41; compared to the combination of midazolam and ketamine &#40;5&#46;51 years&#41; or of midazolam and fentanyl &#40;4&#46;1 years&#41;&#44; differences that were statistically significant &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>001&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">In 258 SA procedures &#40;39&#37;&#41;&#44; a topical or local analgesic was added to the administration of systemic drugs &#40;lidocaine&#47;prilocaine in 16&#46;7&#37;&#44; lidocaine-adrenaline-tetracaine &#91;LAT&#93; gel in 2&#46;9&#37; and local anaesthesia in 15&#46;8&#37;&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Monitoring was used in 480 children &#40;73&#37;&#41;&#44; in most cases by pulse oximetry &#40;95&#46;8&#37;&#41;&#46; In addition&#44; 95 patients &#40;19&#46;5&#37;&#41; underwent heart rate continuous ECG monitoring of the heart rate&#44; 127 &#40;26&#46;4&#37;&#41; intermittent blood pressure measurements&#44; and 21 &#40;3&#46;2&#37;&#41; monitoring of carbon dioxide partial pressure via nasal cannulae&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">We assessed the potential association of monitoring and the type of SA procedure and found that monitoring was less frequent in simple analgesia procedures &#40;19&#37;&#41; compared to the rest &#40;87&#37; of sedation procedures&#44; 70&#37; of SA for mildly painful procedures and 87&#37; of SA in very painful procedures&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>001&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The parents of 352 patients &#40;53&#46;5&#37;&#41; were present during the procedure&#44; and their presence was more frequent in nursing procedures &#40;80&#37;&#41; and surgical procedures &#40;69&#37;&#41; compared to all other procedures in which SA was used &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The presence of parents in relation to the type of SA procedure was more frequent in children that received simple analgesics &#40;73&#37;&#41; or SA for less painful procedures &#40;68&#37;&#41; compared to the rest of SA procedures &#40;40&#37; of patients that underwent sedation and 38&#37; of patients that underwent SA for very painful procedures&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">We also observed that parental presence decreased the more pain the child expressed before the procedure &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41; and the deeper the target level of sedation &#40;<span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The length of stay in the emergency department was less than 1<span class="elsevierStyleHsp" style=""></span>h in 125 procedures &#40;19&#37;&#41;&#44; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h in 359 &#40;54&#46;6&#37;&#41; and more than 3<span class="elsevierStyleHsp" style=""></span>h in 154 &#40;23&#46;4&#37;&#41;&#46; We observed that the stay in the PED was longer &#40;&#62;3<span class="elsevierStyleHsp" style=""></span>h&#41; in patients that underwent sedation &#40;34&#46;6&#37;&#41; or when SA was used for mildly painful procedures &#40;34&#46;9&#37;&#41; compared to the rest of SA procedures &#40;1&#46;7&#37; of patients that received simple analgesia and 16&#37; of patients that received SA for very painful procedures&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The discharge destination was the home in 71&#46;9&#37; of patients &#40;473&#41;&#44; while the other 28&#46;1&#37; &#40;175&#41; required hospital admission&#59; adverse reactions to SA were the reason for admission in only 3 patients &#40;1&#46;7&#37;&#41;&#46; In these cases&#44; the main adverse effect was dizziness associated with vomiting&#44; requiring a 24-h stay in the paediatric ward&#46; We observed that patients that underwent SA for mildly painful procedures were admitted more frequently than patients that underwent SA for very painful procedures &#40;38&#46;5&#37; vs 15&#46;2&#37;&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0235" class="elsevierStylePara elsevierViewall">The purpose of procedural SA is to allow the patient to tolerate painful or unpleasant procedures while maintaining airway reflexes&#44; ventilation and cardiovascular function&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> The guidelines of the American Academy of Pediatrics<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> and the American Society of Anesthesiologists<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> consider the use of procedural SA safe and appropriate for the management of pain and anxiety resulting from diagnostic and therapeutic procedures and methods&#46; In addition&#44; the prevention and alleviation of pain during diagnosis and treatment is a health care quality indicator in PEDs&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The correct preparation of SA procedures is essential for their success&#44; and protocols must be established to guarantee a correct and detailed evaluation of patients prior to any SA procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a> The use of checklists to apply specific guidelines can help prepare for SA procedures correctly and minimise potential adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">As has been the case in previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">12&#44;13</span></a> we observed that most paediatric patients were healthy individuals that were not receiving chronic medication and with normal findings on physical examination&#46; According to the American Society of Anesthesiologists&#44; only patients classified as ASA I or II<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;5</span></a> can be considered candidates for receiving SA from non-anaesthesiologists&#46; In our study&#44; 6 patients were classified as ASA III&#44; and 4 were managed by paediatric emergency physicians with adequate training&#44; a parameter that needs improving&#44; as 2 of these patients were managed incorrectly&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The ASA recommends taking certain precautions prior to SA&#46; It recommends preprocedural fasting in patients undergoing elective procedures to reduce the risk of bronchoaspiration&#44; and does not consider absence of fasting a contraindication in urgent procedures&#44; while recommending an individualised risk-benefit assessment in all other cases&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">To date&#44; several studies have been conducted that failed to establish an association between the incidence of adverse effects and the duration of fasting&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#8211;19</span></a> In our study&#44; the duration of fasting had been documented in most patients&#44; however&#44; we found considerable heterogeneity in this variable&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Sedation and analgesia must be considered a medical intervention apart from&#44; and not part of&#44; diagnostic procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;3</span></a> Therefore&#44; informed consent must be obtained separately before performing any SA procedures&#46; In our study&#44; informed consent was sought in almost every instance&#44; although it was obtained in writing in only 2&#47;3 of the patients&#46; Whether consent was obtained in writing or verbally varied based on the type of procedure&#44; as written consent was sought more frequently in SA procedures associated with a higher risk of complications&#44; such as sedation or SA for very painful procedures&#46; We did not find similar studies in the reviewed literature analysing how informed consent was obtained&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The pharmacological strategies selected for SA depend on the level of anxiety and pain that may be associated with the procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;20</span></a> Drug selection requires a thorough knowledge of the pharmacodynamics&#44; therapeutic effect&#44; dosage and potential adverse effects of the different sedatives and analgesic agents&#44; and providers must unfailingly avoid underdosing for fear of respiratory depression or out of a lack of familiarity with these drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">4&#44;20</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In our study&#44; nitrous oxide was used in nearly half of the procedures&#46; This is an extensively studied drug that is easy to use and associated with few serious adverse effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#44;22</span></a> When it came to the combined use of drugs&#44; the most frequent combination was midazolam and ketamine&#44; drugs that are recommended for SA in children<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;23</span></a> and which have been used frequently in similar studies&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The use of local or topical anaesthesia in addition to systemic drugs is recommended to reduce pain in some techniques or procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#8211;25</span></a> There are numerous topical anaesthetic agents whose administration is not painful&#44; such as lidocaine&#47;prilocaine for intact skin and LAT gel for wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> In our study&#44; a topical or local anaesthetic was used in one third of the patients&#44; most frequently a lidocaine&#47;prilocaine anaesthetic cream&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Monitoring of vital signs is necessary to detect potential adverse effects as soon as possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;26</span></a> In our study&#44; nearly 3&#47;4 of the children were monitored&#44; and the most frequently used monitoring technique was pulse oximetry&#44; which was consistent with the findings of similar studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">23&#44;24</span></a> It seems that most paediatricians are familiar with pulse oximeters&#44; which may be the reason that this technique is used most frequently&#46; Capnography is another method that provides thorough information on the respiratory pattern and the ventilatory status of the patient&#44; and it can detect hypoventilation earlier than other methods&#59; it is a particularly useful approach when providers do not have visual contact with the patient during the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> In our study&#44; capnography was used in 21 patients &#40;3&#46;2&#37;&#41;&#44; probably due to its low availability in PEDs or to physicians not being well acquainted with this technique&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">The use of nonpharmacological interventions for the management of anxiety and pain in paediatric patients is also important&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">9&#44;23&#44;28&#8211;30</span></a> The presence of the parents during procedures is becoming increasingly important&#44; as it is consistent with the current patient- and family-centred approach to health care delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">31&#44;32</span></a> This strategy is not yet implemented in every PED or by all professionals with the justification that the presence of the family may add to the stress of health care providers and hinder the success of the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> However&#44; this is not the case when procedures are carried out by experienced paediatricians&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> In our study&#44; family members were present in a little over half of the procedures&#44; and it is worth noting that the more pain the child expressed prior to the intervention&#44; the less likely it was for parents to be present during the procedure&#46; This suggests that not all providers in paediatric emergency settings feel confident in performing procedural SA&#44; something that has already been described in similar studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;28</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">One of the limitations of our study is that although it was conducted in multiple centres&#44; it was not representative of all of Spain&#44; since several autonomous communities were not represented in the sample&#46; Hospitals were randomly included in the study and the sampling method did not include stratification by autonomous community&#46; Another potential limitation is that we do not know whether participating hospitals had protocols for SA at the time of the study&#44; and therefore were unable to determine whether SA procedures were or not performed according to existing guidelines&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">We would like to conclude by noting that most of the SA procedures analysed in this study were prepared correctly and in adherence with the recommendations of the American Society of Anesthesiologists and the guidelines of the American Academy of Paediatrics&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2017-02-02"
    "fechaAceptado" => "2017-06-20"
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            0 => "Sedation&#8211;analgesia procedures"
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            2 => "Multicentre study"
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            0 => "Procedimientos de sedoanalgesia"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to describe the current practice regarding the preparation of the sedation&#8211;analgesia &#40;SA&#41; procedures performed in the paediatric emergency centres in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A multicentre&#44; observational and prospective analytical study was carried out on the SA procedures that were performed on children under 18 years old in 18 paediatric emergency departments between February 2015 and January 2016&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 658 SA procedures were registered in 18 hospitals of Spain&#44; most of them to children older than 24 months&#46; The type of the procedure was&#58; simple analgesia in 57 &#40;8&#46;6&#37;&#41;&#44; sedation in 44 &#40;6&#46;7&#37;&#41;&#44; SA for a not very painful procedure in 275 &#40;41&#46;8&#37;&#41;&#44; and SA for a very painful procedure in 282 &#40;42&#46;9&#37;&#41;&#46; Informed consent was requested in 98&#46;6&#37; of the cases&#46; The written form was more frequently preferred in the group of patients that received SA for a very painful procedure &#40;76&#46;6&#37;&#41; in comparison to a painful procedure or to simple analgesia &#40;62&#46;9&#37; and 54&#46;4&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The staff that most frequently performed the SA procedures were the paediatricians of the emergency departments &#40;64&#46;3&#37;&#41;&#44; followed by paediatrics residents &#40;30&#46;7&#37;&#41;&#46; The most frequent reasons for the SA were traumatological &#40;35&#46;9&#37;&#41; and surgical &#40;28&#46;4&#37;&#41;&#46; Fasting was observed in 81&#37; of the cases&#46; More than two-thirds &#40;67&#46;3&#37;&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>480&#41; children were monitored&#44; the majority &#40;95&#46;8&#37;&#41; of them using pulse oximetry&#46; The pharmacological strategy used was the administration of one drug in 443 &#40;67&#46;3&#37;&#41; of the cases&#44; mostly nitrous oxide&#44; and a combination of drugs in 215 &#40;32&#46;7&#37;&#41;&#44; especially midazolam&#47;ketamine &#40;46&#46;9&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The majority of the SA procedures analysed in this study have been carried out correctly and prepared in accordance with the current guidelines&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue describir la pr&#225;ctica cl&#237;nica actual de la preparaci&#243;n de los procedimientos de sedoanalgesia &#40;SA&#41; realizados en servicios de urgencias pedi&#225;tricas &#40;SUP&#41; espa&#241;oles&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio multic&#233;ntrico&#44; observacional y anal&#237;tico prospectivo de los procedimientos de SA realizados a ni&#241;os menores de 18 a&#241;os en 18 SUP entre febrero del 2015 y enero del 2016&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se registraron 658 procedimientos de SA en 18 hospitales de Espa&#241;a&#44; la mayor&#237;a &#40;90&#44;7&#37;&#41; en mayores de 24 meses&#46; El tipo de procedimiento fue&#58; 57 &#40;8&#44;6&#37;&#41; analgesia simple&#44; 44 &#40;6&#44;7&#37;&#41; sedaci&#243;n&#44; 275 &#40;41&#44;8&#37;&#41; SA para procedimiento poco doloroso y 282 &#40;42&#44;9&#37;&#41; SA para procedimiento muy doloroso&#46; Se solicit&#243; consentimiento informado al 98&#44;6&#37;&#44; siendo m&#225;s frecuentemente escrito en el grupo de SA para procedimientos muy dolorosos &#40;76&#44;6&#37;&#41; que en procedimientos poco dolorosos o en analgesia simple &#40;el 62&#44;9 y el 54&#44;4&#37;&#44; respectivamente&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El personal que m&#225;s frecuentemente realiz&#243; la SA fueron los pediatras de urgencias &#40;64&#44;3&#37;&#41;&#44; seguidos de los residentes de pediatr&#237;a &#40;30&#44;7&#37;&#41;&#46; Los motivos de la SA m&#225;s frecuentes fueron los traumatol&#243;gicos &#40;35&#44;9&#37;&#41; y quir&#250;rgicos &#40;28&#44;4&#37;&#41;&#46; El ayuno se valor&#243; en el 81&#37;&#46; Se monitorizaron 480 &#40;73&#37;&#41; ni&#241;os&#44; la mayor&#237;a de ellos con pulsiox&#237;metro &#40;95&#44;8&#37;&#41;&#46; La estrategia farmacol&#243;gica utilizada fue la administraci&#243;n de un f&#225;rmaco de forma aislada en 443 &#40;67&#44;3&#37;&#41; de los casos&#44; siendo m&#225;s frecuente el &#243;xido nitroso &#40;50&#37;&#41; y una combinaci&#243;n de f&#225;rmacos en 215 &#40;32&#44;7&#37;&#41;&#44; destacando la combinaci&#243;n midazolam&#47;ketamina &#40;46&#44;9&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los procedimientos de SA analizados en este estudio han tenido una preparaci&#243;n correcta y acorde a las recomendaciones actuales&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The members of the Working Group on Analgesia and Sedation of the Sociedad Espa&#241;ola de Urgencias de Pediatr&#237;a are listed in <a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; M&#237;guez Navarro C&#44; Oikonomopoulou N&#44; Lorente Romero J&#44; V&#225;zquez L&#243;pez P&#44; en representaci&#243;n del Grupo de Analgesia y Sedaci&#243;n de la Sociedad Espa&#241;ola de Urgencias de Pediatr&#237;a&#46; Preparaci&#243;n de los procedimientos de sedoanalgesia en los servicios de urgencias pedi&#225;tricos espa&#241;oles&#58; estudio descriptivo&#46; An Pediatr &#40;Barc&#41;&#46; 2018&#59;89&#58;24&#8211;31&#46;</p>"
      ]
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Previous presentations&#58; Descriptive study of the preparation of sedation and analgesia procedures in paediatric emergency departments&#46; Concepci&#243;n M&#237;guez Navarro&#44; Niki Oikonomopoulou&#44; Jorge Lorente Romero&#44; Paula V&#225;zquez L&#243;pez&#46; Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#44; Spain&#46;</p>"
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            "apendice" => "<p id="par0305" class="elsevierStylePara elsevierViewall">Working Group on Analgesia and Sedation of the Sociedad Espa&#241;ola de Urgencias de Pediatr&#237;a&#58; Ana Isabel Fern&#225;ndez Lorente&#44; Pilar Storch Gracia de Calvo&#44; Gloria Guerrero M&#225;rquez&#44; Eva Benito Ruiz and Elena Sancho Gracia&#44; Olga Serrano Ayestar&#225;n&#44; Cristina Cordero Castro&#44; Cecilio Palomino Mu&#241;oz&#44; Sof&#237;a Mesa Garc&#237;a&#44; Cristina Mu&#241;oz L&#243;pez&#44; Nuria Clerigu&#233; Arrita and Jorge &#193;lvarez Garc&#237;a&#44; Isabel Cubero&#44; Jos&#233; L Fern&#225;ndez Arribas&#44; Alberto Barasoain Mill&#225;n&#44; Juan Antonio Cozar Olmo and Jos&#233; Luis Cuevas Cervera&#44; Clara Garc&#237;a and Carlos Garc&#237;a Vao Bel&#44; M&#46; Jos&#233; Carbonero Cel&#237;s and M&#46; Jos&#233; Carpio Linde&#44; Maite Alonso Salas&#44; Vicente Barea&#46;</p>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital General Universitario Gregorio Mara&#241;on&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital universitario 12 de Octubre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#243;stoles&#44; Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complejo Universitario de Navarra&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital R&#237;o Hortega&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Valladolid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Miguel Servet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Zaragoza&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Universitario de Getafe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Getafe&#44; Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complejo Asistencial Universitario de Salamanca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Salamanca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Cl&#237;nico San Cecilio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Granada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Universitario de Basurto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bilbao&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Infanta Leonor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">List of participating paediatric emergency departments&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ASA&#44; American Society of Anesthesiologists&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">ASA physical status classification&#58; documented in 593 &#40;90&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">529 &#40;80&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Relevant personal history&#58; documented in 656 &#40;99&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unremarkable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">564 &#40;80&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neurologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Ongoing pharmacological treatment&#58; documented in 658 &#40;100&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">596 &#40;90&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asthma medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antiepileptic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antihistaminic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatric drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Fasting&#58; documented in 538 &#40;81&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;1<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#8211;2<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">208 &#40;31&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&#8211;3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109 &#40;16&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Physical examination&#58; documented in 652 &#40;99&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">610 &#40;93&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Risk of potential complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Pain before procedure&#58; documented in 579 &#40;88&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">171 &#40;29&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">154 &#40;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">162 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intense pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92 &#40;15&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 3"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Trauma-related reasons</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fracture reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200 &#40;84&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Luxation reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arthrocentesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Surgical reasons</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Wound suturing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92 &#40;80&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abscess drainage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Treatment of burn&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;10&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Foreign body extraction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;9&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Phimosis&#47;paraphimosis reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>hernia reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intussusception reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Removal of impacted stools&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Infection-related procedures</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lumbar puncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">124 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Nursing procedures</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Peripheral line placement&#47;venepuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;73&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Port &#8211; a-cath placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urinary catheter placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Imaging test</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pharmacological approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total<br><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Simple analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sedation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SA in mildly painful procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SA in very painful procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Single drug</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">443&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nitrous oxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">225 &#40;50&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ketamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72 &#40;16&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;13&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fentanyl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morphine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Combination</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">215&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ketamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;46&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nitrous oxide<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fentanyl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;21&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fentanyl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morphine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>nitrous oxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>nitrous oxide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Midazolam<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>morphine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;2&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fentanyl<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>morphine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;9&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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